| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
517 |
502 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
631 |
618 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
232 |
201 |
$10K |
| D0274 |
Bitewings - four radiographic images |
429 |
421 |
$8K |
| D1206 |
Topical application of fluoride varnish |
170 |
167 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
29 |
$2K |
| D1120 |
Prophylaxis - child |
85 |
81 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$419.40 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$280.00 |